An analysis of theappropriate use of theCaledon ambulanceservice in the OverbergA short report

Selby A. Frank, Pierre J. T. de Villiers

The objective of this study was to determine the possibleextent of the inappropriate use of the ambulances of the

Caledon station of the Overberg Regional Services

Council. The trip sheets of the ambulances for the period

1987 - 1990 were retrospectively analysed, and theappropriateness of calls prospectively determined over a

7-month period. The results showed that the vast majority

of calls (68%) were of a non-emergency nature, and that

only 34% of the trips warranted the use of a fully equippedemergency vehicle. Various cost-containment measuresare suggested.

S Afr Med J 1995; 85: 1185-1186.

The emergency transport of patients by ambulance is animportant and expensive element in a modern health caresystem. Most ambulance services provide both emergencytransportation and care, as well as non-emergencytransportation for medical reasons. The inappropriate use ofemergency equipment and personnel (e.g. a fUlly equippedambulance) for the transportation of non-emergency casesis the topic of this short report.

Ambulance services in South Africa used to be theresponsibility of the respective provincial administra.tions.'In the Overberg Region of the Western Cape, the ambulanceservice is provided by the Overberg Regional ServicesCouncil, as agent for the Cape Provincial Administration.The town and district of Caledon, with a total population of18 362, are served by the Caledon ambulance station withfive fully equipped ambulances.

The total cost of the ambulance service of the Overbergregion during the 1990/91 financial year was R2 747982,68,of which 22% was directly related to the kilometre usage ofthe ambulances. This amounted to a fixed and variable costof R1,54/km and R0,44/km respectively.

In practice the ambulance has to respond to all calls(circular notes 22/1991 and M91/1986, CPA, Hospital +Health Services Branch), including maternity cases,irrespective of the degree of urgency (A. G. MacMahon ­personal communication).

Department of Family Medicine and Primary Care, University ofStellenbosch, Tygerberg

Selby A. Frank. M.S. CH.S.• M.FAM.MED.

Pierre J. T. de Villiers. M.S. CH.S.. D.D.M.. M.FAM.MED.

SAMJARTICLES

As family physician in Caledon at the time of the study,one of the authors (S.F.) decided to undertake a study todetermine the extent of possible inappropriate use of theambulance service, and to identify areas where the servicecould perhaps be improved and costs reduced.

MethodsThe trip sheets of the ambulances of the Caledon station forthe period 1987 - 1990 were analysed in respect of date ofoccurrence, sex, race and age of the patient, the reason forthe call (follOWing the Cape Provincial Administration'scoding), the caller, the distance and the time of day.

Trips where more than one patient at a time weretransported could not be distinguished, but these areunusual in a rural area. It was also impossible to determine,from the available casualty record cards, whether a specifictrip was justified on medical grounds. To overcome the lattershortcoming, a prospective survey was conducted over the7-month period from July 1991 to January 1992. Allambulance patients received at Caledon Hospital during thisperiod were judged by the attending registered nurse tohave been either 'appropriately' or 'inappropriately'transported by a fUlly equipped emergency vehicle.

The diagnosis and the caller (doctor, clinic, police or thepatient or his/her substitute) were also recorded. Althoughthis survey measured only very basic information based onopinion, any more sophisticated protocol would have beenimpracticable for the staff in this rural area.

ResultsA total of 4 692 trip sheets (i.e. records of patientstransported) were analysed retrospectively.

Analysis of the distance travelled per diagnosis group(Fig. 1) shows that only nine diagnosis groups accounted for82% of the total distance travelled by the ambulances of theCaledon station, the majority (68%) being of a non­emergency nature, viz. inter-hospital transfers, discharges tohome, outpatients and maternity.

The highest rate of utilisation was by women in the21 - 40-year age interval, of whom 26,2% were maternitycases.

In the prospective survey; data were recorded for 264consecutive patients transported to the hospital byambulance. In only 34% of these patients was the use of thefully equipped ambulance judged to be necessary; in 47% itwas judged to be unnecessary, while 19% were maternitycases. Less than 4% of the maternity cases werecomplicated.

Of the callers, the district nurse (who examined thepatient) attained the highest accuracy score (57,1%) in theprospective survey, followed by the doctor (31 %) (whousually had not seen the patient). The patient/substitute andthe police scored very low accuracy rates.

DiscussionThis study has shown that by far the largest proportion of

SAMJ Volume 85 No. 11 November 1995 1185 :

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REFERENCES

Accepted 16 Jan 1995.

}.100 years ago • ..

I will endeavour to formulate the elements of some code bi the useof which healthy adults might regulate the quantity ofalcohol theytake, and pledge themselves to keep within a certain boun!ary.

To form such a society or association it would be necessary togive it a name. I suggest "THE R-\TIONAL DRINKERS' BOND" as anappropriate one. The two main principles of membership shouldbe: (1st) never in any period of 24 hours to exceed the quantity ofalcoholic liquor [two ounces of pure alcohol] which I have specifiedas the Anstie allowance; (2nd) for each member to keep a dailyrecord of any quantity of alcoholic liquor he may consume, orrecord the fact that he has taken none.

We wish to thank Or Pierre Rabie, Or A G. MacMahon,Or E. A van Wyk, the registered nurses of Caledon Hospital andMrs Riana Hugo for their advice and assistance.

1. Kotze JM. The role of the ambulance service as part of the health profession.S Atr Med J 1990; 78: 320-323

4. Erlich BA. Inappropriate use of ambulances. N Engl J Med 1984; 311: 801.

~bp ~nntb ~frifHn 3l1rhind jnudurL

10080604020o

All Other

Assault

Psychiatric

Other Medical

Vehicle Accidents

Domestic Accidents

Discharges to Home

Inter-Hasp Transfer

Maternity

Out-Patients

Fig. 1. Distances travelled by Caledon ambulances between 1987and 1990, per CPA diagnosis group.

the workload of the Caledon ambulance service consists ofnon-emergency transportation. Total elimination thereof(however unrealistic) could reduce the total workload by68%, resulting in a possible saving of more than 10% of thetotal costs of the Overberg ambulance service. Thetransportation of outpatients was privatised successfullyfollowing this study.

Another cost-reducing strategy would be to increase theuse of minibus-type vehicles for the transportation of 'non­emergency' patients, instead of the considerably moreexpensive fully equipped ambulance! This could reduce thenumber of fully equipped ambulances needed, the-totalrunning costs and initial capital expenditure.

Improvement of the screening skills of ambulancedispatchers through in-service training should improve theability to assess the validity of calls and the appropriate typeof vehicle for a particular trip.

The public should also be persuaded, by educationalmeans, to use alternative transportation wherever availableand practical. In an area with a better public transportsystem and a population with a higher socio-economicstatus, the vast majority of maternity cases would not needan 'emergency' mode of transport, such as an ambulance.

This study confirmed that the fully equipped ambulancesof the Caledon station are being used inappropriately forvarious reasons, resulting in unnecessary costs. As thissituation may also apply to other ambulance services,further research to investigate this, as well as new cost­saving measures, are indicated.

The foregoing would form the two essential pledges of such anassociation, but as reco=endations I should add: - That forthose between the ages of 21 and 50 the habit of daily life oughtto be to abstain from alcohol, and that the Anstie allowance beonly taken occasionally, say one day in every seven or ten. Thisought to amply cover the requirements of ordinary social life. Formen over 50 the Anstie allowance per diem, simply, at theirdiscretion to take less but not more, woUld suffice; and all under21 years should not be eligible for membership, as they ought toabstain entirely. -

I think if an association of men and women were formed underthe above conditions it might raise a flag under which none needfeel ashamed to stand, and such a membership would not only bea credential of temperance, but an indication of intelligence andself-control.

(Walter T. Harris, S A Medical Journal, November 1895, p. 184.)

50 years ago . ..

Many things we still lack in the Transkei - the absence of asecond opinion which we would often like, or the aid of X-ray andthe pathologist, but these are on their way.

We are not "out of humanity's reach" save as regards juvenileeducation, and most of the existing villages are happy sportingco=unities, with an intimate flavour peculiarly their own.

The General Practitioner has a small European practice, andknowing each patient intimately, his background, home environ­ment, familial traits, etc., is in an excellent position to give himthe attention needed, or to refer him to the right quarter forfurther care. The General Practitioner will remain in the fullestsense, in the Transkei, removing offending molars or domesticdisharmonies with equal alacrity.

I see· no reason why the present happy relations as betweenpatient and doctor should vanish, no matter what Socialisticupheaval ofthe profession results from National Health Service inthe still nebulous future.

(W. Fraser-Shearer, S A Medical Journal, 10 November 1945, p. 410.)

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